臺灣健保署基礎實作指引
0.0.1 - ci-build

臺灣健保署基礎實作指引, published by 衛生福利部中央健康保險署. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/TWNHIFHIR/base/ and changes regularly. See the Directory of published versions

Resource Profile: 事前審查-Claim TWNHIBASE

Official URL: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase Version: 0.0.1
Draft as of 2025-10-29 Computable Name: ClaimTWNHIBASE

此事前審查-Claim TWNHIBASE Profile說明本IG如何進一步定義FHIR的Claim Resource以呈現健保署基礎事前審查之內容

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta Σ 1..1 Meta Metadata about the resource
.... profile Σ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... type Σ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-健保署-申報類別值集 (required)
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-apply-type
..... code Σ 1..1 code 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Required Pattern: preauthorization
... patient SΣ 1..1 Reference(病人資訊-Patient TWNHIBASE) 病人資訊
... created SΣ 1..1 dateTime 申請日期，YYYY-MM-DD，機構自填。
... provider SΣ 1..1 Reference(醫事機構-Organization TWNHIBASE) 醫事機構代碼，必須存在於醫事機構基本資料檔內。
... priority Σ 1..1 CodeableConcept 申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: NHI-健保署-申請案件類別值集 (required)
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
.... supportingInfo:geneInfo 0..* BackboneElement 基因資訊
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-supporting-info-type
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: geneInfo
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWNHIBASE) Data to be provided
... diagnosis S 1..* BackboneElement sequence=1時為主要疾病；sequence>=2代表共病。
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:recordedDate S 0..* date 診斷日期，YYYY-MM-DD，西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt sequence=1時為主要疾病；sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (preferred)
..... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
...... coding:icd10-cm-2023 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (extensible)
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2023-tw
....... code SΣ 1..1 code Symbol in syntax defined by the system
...... coding:icd10-cm-2014 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (extensible)
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2014-tw
....... code SΣ 1..1 code Symbol in syntax defined by the system
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
..... text SΣ 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。
... insurance Σ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence Σ 1..1 positiveInt Insurance instance identifier
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(Coverage) Insurance information

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.subType Base required NHI-健保署-申報類別值集 📦0.0.1 This IG
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base required NHI-健保署-申請案件類別值集 📦0.0.1 This IG
Claim.supportingInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.supportingInfo:geneInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.diagnosis.diagnosis[x] Base preferred 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2023 Base extensible 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2014 Base extensible 臺灣健保署2014年中文版ICD-10-CM值集 📦2017-07-19 臺灣核心實作指引 v0.3
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta 1..1 Meta Metadata about the resource
.... profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase
... type 1..1 CodeableConcept Category or discipline
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-健保署-申報類別值集 (required)
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-apply-type
..... code 1..1 code 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
... patient S 1..1 Reference(病人資訊-Patient TWNHIBASE) 病人資訊
... created S 1..1 dateTime 申請日期，YYYY-MM-DD，機構自填。
... provider S 1..1 Reference(醫事機構-Organization TWNHIBASE) 醫事機構代碼，必須存在於醫事機構基本資料檔內。
... priority 1..1 CodeableConcept 申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: NHI-健保署-申請案件類別值集 (required)
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
.... supportingInfo:geneInfo 0..* BackboneElement 基因資訊
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: geneInfo
..... timing[x] 0..0 When it occurred
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWNHIBASE) Data to be provided
... diagnosis S 1..* BackboneElement sequence=1時為主要疾病；sequence>=2代表共病。
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:recordedDate S 0..* date 診斷日期，YYYY-MM-DD，西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... sequence 1..1 positiveInt sequence=1時為主要疾病；sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (preferred)
..... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
...... coding:icd10-cm-2023 S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (extensible)
....... system S 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2023-tw
....... code S 1..1 code Symbol in syntax defined by the system
...... coding:icd10-cm-2014 S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (extensible)
....... system S 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2014-tw
....... code S 1..1 code Symbol in syntax defined by the system
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
..... text S 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Claim.subType Base required NHI-健保署-申報類別值集 📦0.0.1 This IG
Claim.priority Base required NHI-健保署-申請案件類別值集 📦0.0.1 This IG
Claim.supportingInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.diagnosis.diagnosis[x] Base preferred 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2023 Base extensible 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2014 Base extensible 臺灣健保署2014年中文版ICD-10-CM值集 📦2017-07-19 臺灣核心實作指引 v0.3
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for claim
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-健保署-申報類別值集 (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-apply-type
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Required Pattern: preauthorization
... patient SΣ 1..1 Reference(病人資訊-Patient TWNHIBASE) 病人資訊
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime 申請日期，YYYY-MM-DD，機構自填。
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider SΣ 1..1 Reference(醫事機構-Organization TWNHIBASE) 醫事機構代碼，必須存在於醫事機構基本資料檔內。
... priority Σ 1..1 CodeableConcept 申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: NHI-健保署-申請案件類別值集 (required)
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
.... reference 0..1 Identifier File or case reference
... prescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Prescription authorizing services and products
... originalPrescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... facility 0..1 Reference(Location) Servicing facility
... careTeam 0..* BackboneElement Members of the care team
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:geneInfo 0..* BackboneElement 基因資訊
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-supporting-info-type
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: geneInfo
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWNHIBASE) Data to be provided
..... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis S 1..* BackboneElement sequence=1時為主要疾病；sequence>=2代表共病。
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:recordedDate S 0..* date 診斷日期，YYYY-MM-DD，西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt sequence=1時為主要疾病；sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (preferred)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
...... coding:icd10-cm-2023 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (extensible)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2023-tw
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 1..1 code Symbol in syntax defined by the system
....... display Σ 0..1 string Representation defined by the system
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... coding:icd10-cm-2014 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (extensible)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2014-tw
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 1..1 code Symbol in syntax defined by the system
....... display Σ 0..1 string Representation defined by the system
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
..... text SΣ 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... insurance Σ 1..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence Σ 1..1 positiveInt Insurance instance identifier
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... preAuthRef 0..* string Prior authorization reference number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item 0..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable careTeam members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... detail 0..* BackboneElement Product or service provided
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Item instance identifier
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... subDetail 0..* BackboneElement Product or service provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Item instance identifier
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Claim.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Claim.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.subType Base required NHI-健保署-申報類別值集 📦0.0.1 This IG
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base required NHI-健保署-申請案件類別值集 📦0.0.1 This IG
Claim.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.supportingInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo:geneInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.supportingInfo:geneInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo:geneInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base preferred 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2023 Base extensible 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2014 Base extensible 臺灣健保署2014年中文版ICD-10-CM值集 📦2017-07-19 臺灣核心實作指引 v0.3
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
Claim.procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v6.5
Claim.item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
Claim.item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
Claim.item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
Claim.item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Claim

Summary

Mandatory: 7 elements(5 nested mandatory elements)
Must-Support: 15 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Claim.supportingInfo
  • The element 1 is sliced based on the value of Claim.diagnosis.diagnosis[x].coding (Closed)

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta Σ 1..1 Meta Metadata about the resource
.... profile Σ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... type Σ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-健保署-申報類別值集 (required)
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-apply-type
..... code Σ 1..1 code 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Required Pattern: preauthorization
... patient SΣ 1..1 Reference(病人資訊-Patient TWNHIBASE) 病人資訊
... created SΣ 1..1 dateTime 申請日期，YYYY-MM-DD，機構自填。
... provider SΣ 1..1 Reference(醫事機構-Organization TWNHIBASE) 醫事機構代碼，必須存在於醫事機構基本資料檔內。
... priority Σ 1..1 CodeableConcept 申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: NHI-健保署-申請案件類別值集 (required)
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
.... supportingInfo:geneInfo 0..* BackboneElement 基因資訊
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-supporting-info-type
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: geneInfo
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWNHIBASE) Data to be provided
... diagnosis S 1..* BackboneElement sequence=1時為主要疾病；sequence>=2代表共病。
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:recordedDate S 0..* date 診斷日期，YYYY-MM-DD，西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt sequence=1時為主要疾病；sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (preferred)
..... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
...... coding:icd10-cm-2023 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (extensible)
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2023-tw
....... code SΣ 1..1 code Symbol in syntax defined by the system
...... coding:icd10-cm-2014 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (extensible)
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2014-tw
....... code SΣ 1..1 code Symbol in syntax defined by the system
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
..... text SΣ 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。
... insurance Σ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence Σ 1..1 positiveInt Insurance instance identifier
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... coverage Σ 1..1 Reference(Coverage) Insurance information

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.subType Base required NHI-健保署-申報類別值集 📦0.0.1 This IG
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base required NHI-健保署-申請案件類別值集 📦0.0.1 This IG
Claim.supportingInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.supportingInfo:geneInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.diagnosis.diagnosis[x] Base preferred 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2023 Base extensible 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2014 Base extensible 臺灣健保署2014年中文版ICD-10-CM值集 📦2017-07-19 臺灣核心實作指引 v0.3
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta 1..1 Meta Metadata about the resource
.... profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase
... type 1..1 CodeableConcept Category or discipline
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-健保署-申報類別值集 (required)
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-apply-type
..... code 1..1 code 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
... patient S 1..1 Reference(病人資訊-Patient TWNHIBASE) 病人資訊
... created S 1..1 dateTime 申請日期，YYYY-MM-DD，機構自填。
... provider S 1..1 Reference(醫事機構-Organization TWNHIBASE) 醫事機構代碼，必須存在於醫事機構基本資料檔內。
... priority 1..1 CodeableConcept 申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: NHI-健保署-申請案件類別值集 (required)
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
.... supportingInfo:geneInfo 0..* BackboneElement 基因資訊
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: geneInfo
..... timing[x] 0..0 When it occurred
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWNHIBASE) Data to be provided
... diagnosis S 1..* BackboneElement sequence=1時為主要疾病；sequence>=2代表共病。
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:recordedDate S 0..* date 診斷日期，YYYY-MM-DD，西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... sequence 1..1 positiveInt sequence=1時為主要疾病；sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (preferred)
..... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
...... coding:icd10-cm-2023 S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (extensible)
....... system S 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2023-tw
....... code S 1..1 code Symbol in syntax defined by the system
...... coding:icd10-cm-2014 S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (extensible)
....... system S 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2014-tw
....... code S 1..1 code Symbol in syntax defined by the system
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
..... text S 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Claim.subType Base required NHI-健保署-申報類別值集 📦0.0.1 This IG
Claim.priority Base required NHI-健保署-申請案件類別值集 📦0.0.1 This IG
Claim.supportingInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.diagnosis.diagnosis[x] Base preferred 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2023 Base extensible 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2014 Base extensible 臺灣健保署2014年中文版ICD-10-CM值集 📦2017-07-19 臺灣核心實作指引 v0.3

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/base/StructureDefinition/Claim-twnhibase
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for claim
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subType S 1..1 CodeableConcept 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-健保署-申報類別值集 (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-apply-type
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code 申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Required Pattern: preauthorization
... patient SΣ 1..1 Reference(病人資訊-Patient TWNHIBASE) 病人資訊
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime 申請日期，YYYY-MM-DD，機構自填。
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider SΣ 1..1 Reference(醫事機構-Organization TWNHIBASE) 醫事機構代碼，必須存在於醫事機構基本資料檔內。
... priority Σ 1..1 CodeableConcept 申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: NHI-健保署-申請案件類別值集 (required)
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
.... reference 0..1 Identifier File or case reference
... prescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Prescription authorizing services and products
... originalPrescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... facility 0..1 Reference(Location) Servicing facility
... careTeam 0..* BackboneElement Members of the care team
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... Slices for supportingInfo 0..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... timing[x] 0..1 When it occurred
...... timingDate date
...... timingPeriod Period
..... value[x] 0..1 Data to be provided
...... valueBoolean boolean
...... valueString string
...... valueQuantity Quantity
...... valueAttachment Attachment
...... valueReference Reference(Resource)
..... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
.... supportingInfo:geneInfo 0..* BackboneElement 基因資訊
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Information instance identifier
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-健保署-補充資訊類別值集 (required)
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/base/CodeSystem/nhi-supporting-info-type
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: geneInfo
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWNHIBASE) Data to be provided
..... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis S 1..* BackboneElement sequence=1時為主要疾病；sequence>=2代表共病。
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:recordedDate S 0..* date 診斷日期，YYYY-MM-DD，西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt sequence=1時為主要疾病；sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (preferred)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Closed by value:system
...... coding:icd10-cm-2023 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2023年中文版ICD-10-CM值集 (extensible)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2023-tw
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 1..1 code Symbol in syntax defined by the system
....... display Σ 0..1 string Representation defined by the system
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... coding:icd10-cm-2014 SΣ 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2014年中文版ICD-10-CM值集 (extensible)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/icd-10-cm-2014-tw
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 1..1 code Symbol in syntax defined by the system
....... display Σ 0..1 string Representation defined by the system
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
..... text SΣ 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... insurance Σ 1..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence Σ 1..1 positiveInt Insurance instance identifier
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage Σ 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... preAuthRef 0..* string Prior authorization reference number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item 0..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable careTeam members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... detail 0..* BackboneElement Product or service provided
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Item instance identifier
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... subDetail 0..* BackboneElement Product or service provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Item instance identifier
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Claim.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Claim.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.subType Base required NHI-健保署-申報類別值集 📦0.0.1 This IG
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base required NHI-健保署-申請案件類別值集 📦0.0.1 This IG
Claim.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.supportingInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo:geneInfo.​category Base required NHI-健保署-補充資訊類別值集 📦0.0.1 This IG
Claim.supportingInfo:geneInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo:geneInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base preferred 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2023 Base extensible 臺灣健保署2023年中文版ICD-10-CM值集 📦2024-11-18 臺灣核心實作指引 v0.3
Claim.diagnosis.diagnosis[x].​coding:icd10-cm-2014 Base extensible 臺灣健保署2014年中文版ICD-10-CM值集 📦2017-07-19 臺灣核心實作指引 v0.3
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
Claim.procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v6.5
Claim.item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
Claim.item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
Claim.item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
Claim.item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from Claim

Summary

Mandatory: 7 elements(5 nested mandatory elements)
Must-Support: 15 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Claim.supportingInfo
  • The element 1 is sliced based on the value of Claim.diagnosis.diagnosis[x].coding (Closed)

 

Other representations of profile: CSV, Excel, Schematron